Controlling Asthma:
Preventing Episodes Before
They Occur
Is There A Cure For Asthma?
Asthma cannot be cured, but it can be
Controlled
“We should expect nothing less”!
Goals Of Asthma Control
 Prevent Symptoms
• No coughing or wheezing
• No shortness of breath or rapid breathing
• No waking up at night
 Maintain normal or near “normal” pulmonary function
 Maintain normal activity levels (including exercise and
other physical activities
 Prevent exacerbations of asthma and minimize ER/UC
and hospital visits
 Minimal or no adverse effects from medications
 Meet patients/family’s expectations and satisfaction with
asthma care
Exerts from NAEPP EPR2 Guidelines for Diagnosis and Management of Asthma 1997
Asthma Control
Do Most Students Have It?
Unfortunately NO!
Many students who have asthma:
• Have poor asthma control
• Use “quick relief” medicine (e.g. albuterol) on a
regular basis
• Cough, experience chest tightness, wheezing,
or shortness of breath regularly
• Assume suffering from symptoms are “normal”
• Remain indoors and cannot fully participate in
sports, PE or recess
• Miss school due to asthma
Examples Of Students Whose Asthma
Is NOT Optimally Controlled
• A 10th grader, says he feels fine except when
he runs in PE class, then his chest hurts. He
coughs most mornings and whenever he gets
a cold or virus. He often can’t keep up with
the other kids and needs to stop and rest.
• A 12th grader, carries an OTC Primatine Mist
inhaler & uses it a few times every day. He
says he “grew out” of his asthma.
Examples Of Students Whose
Asthma
IS Optimally Controlled
• A 6th grader, doesn’t need his “reliever”(albuterol)
since consistently using his controller medications
twice daily. He now plays soccer without
developing symptoms or having to take preexercise albuterol.
• A kindergartener, no longer coughs or wheezes
and easily keeps up with the other kids at recess.
Her dad bought special dust mite proof covers for
her mattresses and pillow. She now takes her
controllers daily, uses her Asthma Action Plan, and
sees her health care provider every 6 months for a
well asthma check-up.
Asthma Severity Level vs Asthma
Control
 Asthma Severity Levels (Mild Intermittent, Mild
Persistent, Moderate Persistent, and Severe Persistent)
Based on signs and symptoms before a student
starts on controller medications
Levels can change over time
 Asthma Control (or “Current Asthma Severity”)
Is the students current severity levelregardless if they are on medications,
experiencing symptoms (episodes) and/or able
to be fully active
Asthma Control
Proactive vs Reactive
• Going from a reactive to a proactive
approach
Instead of thinking“ How do I treat these symptoms?”
e.g. with albuterol after the fact
Think“ How
could have the symptoms have been
prevented in the first place?”
e.g. daily controller medications, pre-exercise
meds, asthma action plan, environmental control
Controlling Asthma
Medical
&
Environmental
Management
Controlling Asthma
Medical Management
How To Achieve Good
Asthma Control
 Have regular asthma check-ups with a primary
healthcare provider, even when feeling well
• At least every 6 months (more often if having
symptoms)
 Monitor symptoms and peak flow readings daily
 Ask for and use a personalized Asthma Action Plan
 Know personal green- yellow- red zones, what each
zone feels like and what to do in each zone
Asthma Control Continued...
 Get a flu shot every fall
 Avoid asthma triggers
 Asthma’s not in control? Check in regularly at
school health office for:
• Peak flow check /symptom evaluation
• Lung sounds / respiratory rate check
• Pre-exercise and/or controller meds
• Asthma education
• Care coordination
Asthma Action Plan
See MDH Asthma Action Plan
F1
Written Asthma Action Plans
 Developed by the health care provider for each
individual child with asthma
 Medications are determined by asthma severity
level
 Based on symptoms and peak flow rates
 Lists daily & rescue medications
 Symptom management and emergency plan
 Copies to be shared by clinic, family and school
Asthma Action Plan Zones
Green Zone: All Clear/Breathing Good/Go
– No asthma symptoms and/or
– Peak flow 80-100% Predicted or Personal best
 Yellow Zone: Caution/Slow Down
– Some asthma symptoms and/or
– Peak flow 50-80% Predicted or Personal best
 Red Zone: Medical Alert/Stop
– Severe asthma symptoms and/or
– Peak flow < 50% Predicted or Personal best
What Can A Student Do To Stay In The
Green Zone?
Select The Incorrect Answer
A. Take their controller (anti-inflammatory)
medication every day
B. Avoid cigarette smoke and other asthma
triggers
C. Take their pre-exercise (usually reliever)
medicine before P.E. or at recess
D. Wash their bathroom often with bleach to
avoid mold and mildew build-up
What Can A Student Do To Stay In The
Green one?
Select The Incorrect Answer
A.Take their controller (anti-inflammatory)
medication every day
B. Avoid cigarette smoke and other asthma
triggers
C. Take their pre-exercise (usually reliever)
medicine before P.E. or at recess
D. Wash their bathroom often with bleach to
avoid mold and mildew build-up
If A Student Is In The Yellow Zone,
They Should:
A.Be cautious. Breathing isn’t their best.
Take action
B.Eat a lot of yellow foods such as
bananas, which are high in potassium
C.Automatically stay home from school
D.Call their doctor or nurse practitioner
immediately
If A Student Is In The Yellow Zone,
They Should:
A. Be cautious. Breathing isn’t their best. Take
action
B. Eat a lot of yellow foods such as bananas,
which are high in potassium
C. Automatically stay home from school
D. Call their doctor or nurse practitioner
immediately (correct answer: call if they aren’t
fully back into the green zone within 48-72
hours).
R1
Which Is One Symptom/ Clinical Indicator
Is NOT Associated With The Red Zone?
A. Mild coughing
B. Peak Flow reading < 50% of personal best
C. Significant breathing problems
D. Persistent wheezing or no wheezing at all
indicating severely limited aeration
Which Is One Symptom/ Clinical Indicator
Is Not Associated With the Red Zone?
A. Mild coughing
B. Peak Flow reading < 50% of personal best
C. Significant breathing problems
D. Persistent wheezing or no wheezing at all
indicating severely limited aeration
Activity
Group Case Discussion
 The first month of school, you are called to an
elementary school by a substitute teacher. She
sent a 3rd grader to the nurse’s office alone,
and told her to lay down.
 When you arrive, child has neck vein
distension, accessory muscle retractions,
dark/dusky color. No inhaler available
 Mom is 45 min. away. Grandma is in town
 WHAT DO YOU DO?
Answer:
Provide emergency care and
medication per AAP/ Management
plan and
CALL 911!
Controlling Asthma Environmental Management
Common Environmental Triggers At
Schools
• Indoor Triggers
• Outdoor Triggers
 Animals with fur
 Ozone
 Dust mites
 Particulate matter
 Mold
 Diesel exhaust
 Pests
 Chemicals
(e.g. re-surfacing the
playground or roof, etc.)
 Secondhand smoke
 Chemicals
(e.g. strong smelling
cleaning supplies,
perfume, air fresheners)
Animals
• Dander, urine & saliva are triggers
• Triggers remain months after animal pet removed
• Actions:
 Prohibit/remove animals from schools if able
 If removal is not possible:
» Keep animals in cages or localized areas
» Clean cages often
» Keep animals away from fabric furniture, carpet &
ventilation system
» Locate sensitive students away from animals
 Pre-notify parents if animals with fur/feathers visit
• Sample Animals in School Guidelines in manual
R1
Dust Mites
• Both cause & trigger asthma; live in pillows, carpet, fabriccovered furniture, curtains
• Actions:
 Keep classrooms clutter-free
 Make informed decision: presence of carpet
 Vacuum often when people with asthma/allergies are
gone (HEPA filter vacuum cleaners may help)
 Pillows/mattress/box spring in dust-mite proof zipped
covers
 Wash bedding and stuffed toys weekly in HOT water
(>130 degrees F)
 Keep room humidity < 50% if possible
Mold
• Moisture control is key
• Actions:
 Report leaks and wet/moist areas right away
 Wash mold off hard surfaces
 Replace moldy porous items such as ceiling tiles
& carpet
 Avoid carpet in areas with regular moisture such
as drinking fountains & sinks
E9
Pests
• Droppings or body parts can trigger asthma
• Actions:
 Use integrated pest management (IPM) methods
»
»
»
»
Don’t leave food, water or garbage exposed
Don’t eat or drink in classroom
Seal entry points for pests
Use pesticides only as needed
 Parent Right to Know Act: must notify parents &
employees when using specific pesticides
F32, F33, F34
Secondhand Smoke
• Causes asthma in young children & triggers asthma
in children & adults
• Contains over 4,000 substances
• State law prohibits tobacco use in K-12 public
schools
• Actions:
 Enforce smoking bans (for anyone on school property)
 Include anti-smoking message in curriculum
 Encourage parents/guardians to quit smoking or to not
smoke inside their home
Outdoor Air
• Ozone & fine particles are concerns in MN
• Staff have little control over outdoor air
• Actions:
 Sign
up for Air Quality Index notice
» Pollution Control Agency sends e-mail alerts when
they expect poor air quality (regional)
 Avoid being outside at high pollen count times,
especially if students are allergic to particular
pollen/s
Sept. 14, 2000/June 28, 2001
The AQI
Average Number Of Alerts
6-12 alerts per year in last few years
Most due to PM2.5
Not violation of federal air quality
standards thus far
Health issues still valid
2003 – Air Pollution Health Alerts
Expanded AQI to Duluth, St. Cloud,
Rochester
Detroit Lakes, Marshall coming soon
Expanded media coverage (Pioneer
Press, TV meteorologists, health reporters,
others)
Expanded web & e-mail alert signup
MPCA’s AQI web page 1
MPCA’s AQI web page 2
School Buses
• State law requires:
 Reduce unneeded idling in front of schools
 Reroute bus parking zones away from air
intakes, if possible
• Actions:
 Post “no idling” signs
 Maintain bus fleet
 Invest in cleaner fuels
 Purchase newer, cleaner buses over longterm
R2, R3, R4
Other Environmental Issues
•
•
•
•
Indoor Air Quality Management Plan
Cleaning & cleaning products
Flooring
Air cleaners
R7
Home Environment Resources
• US Environmental Protection Agency
 Asthma Home Environment Checklist
» 8 page checklist of common asthma triggers
» Questions to identify triggers & action steps
 Clear Your Home of Asthma Triggers fact sheet
• EPA website
www.epa.gov/iaq/asthma/resources.html
Communication &
Care Coordination
Key Communication Triad
Parent/
Guardian
Child
School Health
Office
Health Care
Providers
Care Coordination / Communication
(Health Assistant / Paraprofessional/LPN Role)
 Health Assistants / Paraprofessionals / LPNs
must alert LSN/PHN/RNs of students who come
in frequently with asthma type symptoms
 Monitor students with asthma as directed by
LSN/PHN/RN
 Perform delegated responsibilities once skills
have been validated per district/school policies
Care Coordination /Communication
(LSN/RN/PHN)
• Examples of asthma care coordination
activities
 Request AAPs on students
 Review AAP and/or IHP and develop/modify plan
for care coordination
 Determine medical insurance status and connect
to appropriate provider(s)
 Arrange for special transportation (in rare cases)
prn
 Connect to community resources
Care Coordination/ Communication
• Communicating with Students
• Educate them to:
 Follow an individualized Asthma Action Plan
 Avoid or control exposure to their triggers
 Use medication appropriately
• Long-term-control medicine
• Quick-relief medicine
 Monitor symptoms and response to treatment
• Understand symptoms and peak flow levels
• Seek a health care providers help when needed
Communicating w/ Students
Continued..
Get regular follow-up care
Be able to exercise/ play at optimal levels
Be responsible for carrying and using their
asthma medications per school policies
Ask for help when they need it!
Care Coordination/ Communication
• Communicating with parents/guardians
 Review parent/guardian and student questionnaires
 Determine current asthma severity levels
 Provide education to family/student as needed
 Encourage questions and give feedback
 Contact parent/guardian every time a student has asthma
symptoms and or if having poor asthma control
 Obtain a signed consent to release/ share information
F11, F14, F3, E1, F7
Care Coordination / Communication
• Communicating with health care providers
 Report status changes and re-evaluation needs
 Advocate for pre-exercise and /or controller
medications as appropriate
 Arrange for asthma education
 Complete IHP and/or ECP if needed
 Document as appropriate in Pupil Health Record
 Evaluate symptoms, lung sounds and peak flow
regularly on poorly controlled students
F17, F18
Communicating With School Staff
 Share information with staff on a need to know
basis only
 Maintain student confidentiality
 Provide general asthma education to staff
proactively
 Provide asthma first aid training to staff
 Act as a resource to school staff for questions and
concerns
Health Office Scenario
• A 4th grade student who you have not seen
in the health office this year for asthma
symptoms, has a diagnosis of asthma in her
record, and has albuterol MDI / orders in the
health office at school, but no Asthma Action
Plan. She comes into the health office with a
persistent cough.
• What would you do for her?
Health Office Scenario
Continued...
• Actions
 Physical Assessment (respiratory rate, breath
sounds, severity of symptoms)
 Ask what she was doing before coming into
the health office / what may have precipitated
symptoms
 Ask frequency of day / nighttime symptoms
 Check height/PF chart for predicted PF and
initiate Asthma Record
F5
Health Office Scenario
Continued...
Check her Peak Flow reading and document in
SHOAR F4
» Instruct the child how to do a PF reading
 Give albuterol (observe inhaler technique)
Teach/reinforce proper inhaler technique, use of
spacer or holding chamber with inhaler
 Monitor her for response to medication
 Send note home with the child using the AVN
and a PAQ F11
F8
Health Office Scenario
Continued...
• Two days later, she returns to the health
office, with cough and shortness of breath
• What would you do for this 4th grader first?
• What would be the next steps or what else
should you do at this point?
Health Office Scenario Continued…
• What else should you do now?
 Re-evaluate her respiratory status and treat
as appropriate
 Call her parent / guardian to notify, ask for
parent questionnaire/more info.
 Suggest she see her health care provider
 Ask the child to come see you the next day
for a follow up check
 If you have consent, fax Asthma Medical
Referral/Request to health care provider
F9
Asthma Management In The
School Health Office
Sample Forms For Optimal
School Asthma Management
Key Asthma Tools
• Components of Asthma Management in the Health
Office E2, E3
• Asthma Action Plan w/ imbedded consents, parent
letter F1, F2
• Asthma Visit Notification form F7, F8
• Asthma Medical Request/Referral F9, F10
• Pathway for Acute School Asthma Care E6, E7
• Emergency Care Plan - Asthma F18
• Individualized Health Plan - Asthma F17
Key Asthma Tools
• Parent/Guardian Breathing/Asthma Questionnaire
F11, F12, F13
• Student Breathing/Asthma Questionnaire F14,
F15, F16
• School Health Office Asthma Record F4, F5, F6
• Self-administration Asthma Medication
Authorization F19, F20
• First Aid for Asthma poster / pocket cards E4, E5
• Asthma Green/Yellow Zone Update F23, F24
• Permanent Health Office Pass F25
Components Of Asthma Management
In School Health Office
Two Models Provided in School Asthma Manual
LSN + Health Assistant (Mpls. Public Schools model) E2
• LSN + Secretary (St. Paul Public Schools model) E3
•
Purpose: Provides job specific instructions for providing
quality asthma care in the school health office
• Licensed School Nurse, Public Health Nurse, Registered
Nurse
• Licensed Practical Nurse
• Health Aid/Service Assistant / Paraprofessional
• Secretary / Administrative Assistant
Asthma Screening Questions
Include these 3 questions into your existing
student health questionnaire
1. Does your child have asthma or other breathing
problems?
2. Has your child ever been diagnosed by a doctor as
having asthma?
3. Has your child had episode(s) of wheezing
(whistling in the chest) in the last 12 months?
Asthma Action Plan (AAP)
• Purpose
Provides a plan to guide the asthma management of
individual students
Includes imbedded consents:
» Allow parents/guardians and providers to give
permission for medications to be given at school
» Allow for sharing/release of information between school,
clinic, hospital, child care provider and home care
• Available in English and Spanish
Asthma Visit Notification Form
(AVN)
• Purpose
Increases communication between the
school health office, parents/guardians, and
primary care/asthma care providers
Fill out and send home whenever the student is
in the health office with asthma symptoms
Or when delegated by the LSN/PHN/RN
F7,F8
Asthma Medical Request
(AMR)
• Purpose
To facilitate communication and care coordination
between the health care provider and the school
nurse about the student’s asthma
status/management
 Fill out and fax, mail to health care providers
 You must have the parents written consent to collect
medical information first
F9, F10
Pathway for Acute School
Asthma Care
• Purpose
Assists school nurses in making decisions
regarding the provision of acute asthma care
in the school health office or other school
setting
Designed to be used for students experiencing
mild, moderate or severe asthma symptoms
E6, E7
Asthma Emergency Care Plan
(ECP)
• Purpose
Provides special instructions to selected
school staff on how to respond to an
asthma emergency
Used with students with severe or labile
asthma
Individualized for each student with asthma
F18
Asthma Individualized Health
Plan (IHP)
• Purpose
 Provides a Nursing Plan of Care and promotes
care coordination and communication between the
school nurse and health office staff regarding
students whose asthma is not in good control
• Also used to document special education
nursing services
F17
Parent / Guardian Asthma
Questionnaire (PQ)
•
Purpose
•
Used To:
 Gather baseline information about the child’s
asthma symptoms
 Determine the child’s asthma severity level
 Determine if the child’s asthma is under
control
 Develop an appropriate plan of care
Typically used for students in 5th grade or lower
Student Breathing Questionnaire
(SBQ)
• Purpose
Used to:
Determine the student’s asthma severity level
Determine if the student’s asthma is under control
Develop an appropriate plan of care
Determine student’s familiarity of their meds,
triggers, symptoms etc.
• Used with students in grades 6th grade or higher
F14, F15
School Health Office Asthma Record
(SHOAR)
• Purpose
Provides a user-friendly document on which to
record many aspects of a student’s asthma care
• Allows health office staff to:
 Record Asthma Medication
 Record Peak Flow Readings
 Document Asthma Symptoms
 Document Education
F4, F5
Self-Administration Of Asthma
Medication Authorization / Agreement
• Purpose
To systematize practice regarding selfcarrying of asthma medications between
schools
Promotes strong asthma self care skills in
students
Agreement between student and school nurse
 Used in conjunction with an Asthma Action
Plan or may stand alone
F19, F20
First Aid For Asthma Poster /
Pocket Cards
• Purpose
Provides basic first aid care for asthma and asthma
symptoms with directions when to call 911
 Place posters in locations in the school where students
and staff are usually present
 Pocket cards may be given to physical education teachers
or coaches or other staff as needed
E4, E5
Prioritizing In A Busy School
Health Office
There’s Never Enough Time,
What Can I Do?
• It isn’t possible for school health office staff
to get deeply involved with every student
who has asthma so • Prioritization is essential!
Determine which students seem to be having
the most difficulty, and focus on them first
How Do I Prioritize?
1. Prioritize by “current asthma control /
severity level”
2. Focus first on students with the poorest
asthma control regardless of severity level
3. Start working with students whose asthma is
poorly controlled in the moderate to severe
persistent asthma levels
Which Of These Students With
Asthma Would You Focus On First?
1. A boy with diagnosed moderate persistent asthma
who can run, play, attend school without
symptoms and rarely uses his albuterol
2. A girl with current mild persistent asthma who is
unable to fully participate in PE class
3. A girl who’s original severity level was severe
persistent but whose “current asthma severity
level” (control) is moderate persistent. She can
play outside better than originally, but still needs
albuterol for symptoms 3-4 times a week at school
Which Of These Students With
Asthma Would You Focus On First?
3. A boy with diagnosed moderate persistent
asthma who can run, play, attend school
without symptoms and rarely uses his
albuterol.
2. A girl with current mild persistent asthma
who is unable to fully participate in PE class.
1. A girl who’s original severity level was
severe persistent but whose “current asthma
severity level” (control) is moderate
persistent. She can play outside better than
originally, but still needs albuterol for
symptoms 3-4 times a week at school.
Education In The School
Health Office
Components Of Student
& Family Education
Concept of asthma control
Pathophysiology of asthma
Environmental control and triggers
Controller vs. reliever medications and
refilling medications
Use of Asthma Action Plan and treatment
of episodes
Peak flow meter use
Components Of Student
& Family Education Cont…
Signs and symptoms of respiratory distress
and when to seek help
MDI with spacer / DPI technique
Nebulizer use and technique (prn)
Importance of relationship with provider and
well-asthma check-ups
Flu shot every fall
Self-care, especially for students as they get
older
Strategies To Educate When
Time Is Limited
Give short asthma education messages
when meeting with with students
Use innovative / interactive asthma
education tools (computerized asthma
games, internet-based asthma control
tools, videos) with students / families
The Best Laid Plans..
You can increase the likelihood of asthma
management success (compliance) by:
1. Reviewing Asthma Action Plan and making
sure student understands how to use it
2. Ask how controller medications fit into the
student’s daily routine (can they handle it?)
3. Identify obstacles or barriers to the
student/family carrying out the plan as
prescribed
“I Can’t Manage This By Myself.
Who Else Should Be Involved”?
Referring To Community
Resources For Education And
Case Management
 LSN/PHN/RNs can utilize case managers, home
visiting professionals, and asthma educators from
health plans, hospitals, clinics, public health, to
help educate and/or case manage students whose
asthma is poorly controlled
 Connect students/family to community education,
asthma camp, other community resources
Coordinated School Health:
Partnering For Optimal Asthma
Management In Schools
CDC’s Strategies For Addressing Asthma
Within A Coordinated School Health
Program
Six Strategies
1. Establish management and support systems
for asthma-friendly schools
2. Provide appropriate school health and
mental health services for students with
asthma
3. Provide asthma education and awareness
programs for students and school staff
Strategies Continued…
4. Provide a safe and healthy school
environment to reduce asthma triggers
5. Provide safe, enjoyable physical education
and activity opportunities for students with
asthma
6. Coordinate school, family, and community
efforts to better manage asthma symptoms
and reduce school absences among students
with asthma
Asthma Goals For School
Health
Healthy school environment
Health services in school
Asthma education
Supportive policies
Sound communication
1997 National Asthma Education and Prevention Program (NAEPP)
Spearheading School-wide Asthma Best
Practices At Your School
See Checklist in manual for suggestions
Create a multi-disciplinary plan for improving
asthma management in your health office,
school and/or district
Improve own practice
Educate other school staff
Involve all disciplines within the school
setting
Community Involvement
Get involved with the Minnesota Asthma
Coalition, and/or the regional Asthma
Coalition in your area
Contact your legislators and insist on
legislation to support asthma-friendly
policies
 Anti-smoking laws
 Healthy housing initiatives
 Supporting Clean Indoor act
 Support stricter pollution control measures
Conclusion
Asthma is a big challenge for Minnesota
Working together with parents and health
care providers, we have the ability to
positively and dramatically impact the
health of children who have asthma!